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INTRODUCTION

KEY POINTS

  • Alopecia is classified as cicatricial or noncicatricial.

  • Classification of cicatricial alopecia is often confusing and controversial.

  • Central centrifugal cicatricial alopecia (CCCA) is responsible for more cases of cicatricial alopecia than all other forms in African American women.

  • Prompt diagnosis and aggressive treatments of alopecias are warranted to halt progression of disease and salvage viable hair follicles.

  • Many disorders have overlapping clinical and histologic features.

  • Scalp biopsy and histopathologic evaluation are strongly recommended for diagnosing alopecia in skin of color patients.

  • Medical therapy and education on proper hair care practices are imperative in the treatment of alopecia.

Alopecia is the fifth most common dermatologic diagnosis in African American patients, and severe central alopecia affects 5.6% of African American women.1,2,3 A systematic approach to the diagnosis of alopecia in the skin of color patient population is necessary to allow for adequate and appropriate treatment of disease. Alopecias can be subdivided into cicatricial (also known as scarring) and nonscarring subcategories, although overlap may occur. The diagnostic hallmark clinically distinguishing between these types of alopecia is the loss of follicular ostia in cicatricial alopecia, which may be typified by increased interfollicular distance on physical examination. Careful history and physical examination, as well as laboratory testing and/or biopsy, may be necessary for definitive diagnosis. Treatment should be based on clinical and histopathology results.

APPROACH TO THE PATIENT WITH ALOPECIA

The evaluation of the patient with alopecia must be comprehensive and include the following:

  • Complete hair history including: onset of hair loss, loss of the full hair shaft versus hair breakage, localized versus diffuse, symptoms (itching, pain, burning, tenderness), recent illnesses/stressors (eg, death of loved one)

  • Discussion of hair care practices: relaxers (frequency of use, type of relaxer), frequency of heat use, frequency of washing/conditioning, styles (braids, weaves, locks, tight ponytails)

  • Full pertinent medical history should be obtained, including: history of menstrual cycle regularity/flow, history of medications (new, dose changes, herbal), history of anemia or thyroid disease

  • Clinical examination of scalp and all hair-bearing areas

  • Laboratory testing as indicated

  • Histopathologic evaluation

PRIMARY CICATRICIAL ALOPECIAS

Cicatricial alopecia represents a poorly understood group of disorders characterized by a common final pathway of replacement of the hair follicle structure by fibrous tissue.4 The North American Hair Research Society (NAHRS) classifies the primary cicatricial alopecias by histopathologic findings: lymphocytic, neutrophilic, mixed, and nonspecific.4 Sperling5 identified five distinct pathologic forms of scarring alopecia: chronic cutaneous lupus, lichen planopilaris, dissecting cellulitis, acne keloidalis nuchae, and central centrifugal cicatricial alopecia (CCCA)5 [Table 38-1]. Overlapping clinical and histopathologic features may lead to difficulty in distinguishing diagnoses, such that these entities often are included in the differential diagnoses of the other. We will discuss these five types of cicatricial alopecia in further detail as they pertain to darker-skinned populations.

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